Psychiatry Flashcards
A 46 year old man attends the GP with uncontrollable restless legs. He’s unable to sit still and feels a constant need to move around. He has depression for which he takes a typical antipsychotic. He’s visibly distressed and has not stopped moving since he arrived. Which antipsychotic drug effect best matches this description?
B
Acute dystopia reaction = involuntary muscle contractions induced by medications. Typically caused by antidopaminergic drugs, dopamine receptor antagonists and some serotonergic drugs.
Akathisia = inability to remain still, typically involves intense sensation of unease and inner restlessness
Metabolic syndrome = combination of abnormalities including insulin resistance, impaired glucose tolerance, abdominal obesity, reduced high-density lipoprotein (HDL)-cholesterol levels, elevated triglycerides, and hypertension.
Parkinsonism = Tremors, muscle rigidity and bradykinesia
Tardive dyskinesia = involuntary movement of the jaw, lips and tongue. Most commonly seen as a side effect of antipsychotic drugs.
A 42 year old woman attends general practice with a four-month history of nausea and headaches. She has depression and has been taking sertraline for the past six months. She believes the anti-depressant is working but feels the side effects are disrupting her life. Which is the most appropriate additional medication?
What drug class is venaflaxine?
SSRI
What drug class is imipramine?
TCA
What drug class is moclobemide?
MOAi- monoamine oxidase inhibitor
How do you treat mild depression and depression in young people?
Start with watchful waiting for 2 weeks
In young people consider talking therapy referrals before antidepressants
What is the first line antidepressant for children?
Fluoxetine
Can consider sertraline or escitalopram as second line pharmacological treatment
A 42 year old woman attends general practice with a four-month history of
nausea and headaches. She has depression and has been taking sertraline
for the past six months. She believes the anti-depressant is working but feels
the side effects are disrupting her life.
Which is the most appropriate additional medication?
Mirtazapine
This is an atypical antidepressant that can be prescribed alongside SSRIs to reduce their side effects.
How do you monitor lithium levels for patients prescribed lithium?
-must monitor lithium levels weekly until levels are stable, even when changing dose
-must monitor 12 hours post dose
-must monitor lithium levels every 3 months once stable
-need to measure weight/BMI, Us & Es, estimated eGFR, calcium and thyroid function tests every 6 months- more often if impaired renal function present
A
This woman has bipolar disorder associated with halllucinations
If she has psychosis outside of the mania and depression this could be considered schizoaffective disorder i.e. the psychosis is not mood dependent.
This person’s mood changes do not correlate with a schizophrenia diagnosis.
How do TCAs work?
They block reuptake of monoamines into presynaptic terminals
What type of drug is phenelezine?
Monoamine oxidase inhibitor (MAOi)
NOTE: you CANNOT eat dried fruit or drink alcohol
Why do you have to avoid tyramine containing foods when taking an MAOi?
MAOis can cause you to have really high tyranny levels that can cause rapid spikes in blood pressure that can be an emergency.
Symptoms include severe headache, chest pain, flushing, sweating, diarrhoea, SOB.
Who can provide an emergency detention certificate? And how long does it last?
An FY2 or higher grade doctor in conjunction with an MHO.
Lasts 72 hours from patient being admitted and detention papers have been sent to hospital managers.
Can be used if it’ll takes too long to get short term detention certificate and you need to detain patient in the short term.
Who can authorise a short term detention certificate? How long does it last?
AMP i.e. a speciality doctor such as a consultant psychiatrist with an MHO’s consent.
This is used to treat a mental health disorder (MUST be a known diagnosis) or determine needed treatment.
It lasts up to 28 days.
What is a compulsory treatment order used for? How long does it last?
Longer term treatment up to 6 months
After 6 months can be renewed and then renewed on a yearly basis.
Who approves a compulsory treatment order?
Mental health tribunal
(MOH and medical reports are also involved)
What section of the metal health act gives nurses the ability to detain patients for up to 6 hours?
Section 5 (4)
What section of the metal health act gives doctors the ability to detain patients for up to 72 hours?
Section 5 (2)
-Chlorodiazaperoxide is first line for alcohol detoxification
-Acamprostate, dilsufram and naltrexone can be used used for relapse prevention
When does postpartum psychosis occur?
Within the first two weeks
note: baby blues occurs around the same time so be careful distinguishing between the two
A 43 year old man is described by his colleagues as ‘cold and strange’.
He has never been in a meaningful relationship, preferring to live alone. At social events he seems distant and displays little emotion. He has few friends and his only hobbies include reading alone. His parents say that he has been this way since he was a child.
Which personality disorder is this patient most likely to have?
-avoidant
-schizoid
-schizotypal
-narcissistic
-paranoid
Schizoid personality disorder is: characterised by an enduring pattern of detachment from social relationships and a restricted range of emotional expression. Displays a pervasive lack of interest in or desire for interpersonal relationships, often preferring solitary activities. Shows an emotional coldness, detachment, or flattened affectivity
A 45-year-old male with a schizophrenia diagnosis is seen on the ward round. They are very distressed about having their loved ones visit, as they claim they are not who they say they are. The family are very confused, as the patient was not refusing visits the week before, and none of them have changed appearances. They are worried their family member may be getting sicker.
What is the name of the delusion the patient is demonstrating?
A 45-year-old male with a schizophrenia diagnosis is seen on the ward round. They are very distressed about having their loved ones visit, as they claim they are not who they say they are. The family are very confused, as the patient was not refusing visits the week before, and none of them have changed appearances. They are worried their family member may be getting sicker.
What is the name of the delusion the patient is demonstrating?
Capgras delusion
A 52 year old woman comes to the GP surgery asking for help. She informs you that she has difficulty making everyday decisions and relies on an excessive amount of advice and reassurance from others. She adds that she has no idea how to look after herself and often relies on partners telling her exactly what to do. In her free time, she has difficulty initiating projects due to a lack of self-confidence and feels helpless when alone. Throughout the consultation, she is very preoccupied with her fear of being left to take care of herself when her partner dies.
What personality disorder is this patient most likely to have?
-histrionic
-borderline
-paranoid
-dependent
-avoidant
What are the side effects of lithium at therapeutic dose?
What are the symptoms of lithium toxicity?
A 30-year-old female patient with a history of bipolar disorder approaches her GP seeking advice about pregnancy. She wants to try for her first child but is worried about the effect her medication will have on the developing baby.
What is the correct advice to give about taking lithium in pregnancy?
Stop lithium in first trimester-
In first trimester lithium can cause increased risk of miscarriage and increased risk of heart defects such as Ebstein’s abnormality- leaflets of tricuspid valves are displaced so there’s large right atrium and small right ventricle
What is conversion disorder?
Conversion disorder is the presence of neurological symptoms without any underlying neurological cause.
How long after the birth of the baby can postpartum depression develop?
Up to one year after the birth of the baby
What is the difference between an acute stress reaction and post traumatic stress disorder?
Acute stress reaction subsides after a few days or months. PTSD has to be present for at least a month.
A 27 year old woman with a background of previous depression has been staying in a mental health institution for assessment after a recent episode of mania for further assessment.
The team looking after her have made a diagnosis of Bipolar Disorder and although treatment has started she is still unwell and thought to be a danger to her self. The original order that she was detained under for assessment has expired and the team think they need to apply a different section of the mental health act to continue her treatment.
What section of the Mental Health Act 1983 can be used to detain patients for up to 6 months for treatment?
A 37-year-old retail worker is commenced on clozapine to manage his treatment-resistant schizophrenia. The clinician discusses the potential benefits and side effects of the drug with him.
Which of the following is the most common side effect of clozapine?
-sudden death
-paralytic ileus
-neuroleptic malignant syndrome
-constipation
-agranulocytosis
A 25 year old male diagnosed with Schizophrenia attends the psychiatry outpatients clinic. He currently takes Olanzapine 20mg per day. After being on the drug for a month, he complains of significant side effects associated with the drug.
Which of the following is the most likely side effect of Olanzapine?
-weight gain
-gynaecomastia
-extrapyramidal side effects
-bradycardia
-agranulocytosis
A 57-year-old man is reviewed by his community mental health team after concerns are raised regarding his eccentric, out of his normal dress sense. He confirms that he now only dresses in purple as other colours may bring him bad luck. Although he admits he does not have any evidence for this belief, he states he prefers to dress in purple anyway as ‘it doesn’t hurt anyone’. He does not currently take any medication.
On assessment, his speech is overly formal, with good eye contact. It is noted that he sits very close to the clinician. He does not appear to be responding to unseen stimuli.
Which of the following personality disorders best describes the behaviour of this patient?
-emotionally unstable personality disorder
-schizotypal personality disorder
-schizophrenia
-antisocial personality disorder
-schizoid personality disorder
A 48-year-old male inpatient has started shouting in the ward. He says he can see bugs crawling on the ward and that they are on his skin. He is very agitated and sweating profusely. He is currently an inpatient, as he was deemed to be unsafe for discharge from A&E 3 days ago.
What is the most likely cause of these symptoms?
-Hepatic encephalopathy
-Wernicke’s encephalopathy
-Lewy body dementia
-Alcohol ketoacidosis
-Delirium tremens
A 45-year-old woman is referred to the acute medical unit of the local hospital with tremor and new confusion. She has been unwell for the last week with diarrhoea and vomiting. She has a past medical history of bipolar disorder and takes lithium daily. On examination, she has horizontal nystagmus and slurred speech. She is tremulous. Her GCS is 14 (E4V4M6). Her physical examination is unremarkable but towards the end of the exam she sustains a 2-min self-terminating seizure. An urgent serum lithium level is requested, which comes back at 3.7 mmol/l (0.6–0.8).
What is the most important step in the management of this patient?
Haemodialysis
A 37-year-old male is arrested following a break-in. He is very agitated in his cell and has several large cuts on his hands from smashing a window. He has a record with the police with incidents from as young as 13, where he was cautioned for reckless behaviour involving bikes and other crimes such as petty theft and grievous bodily harm (GBH). He was excluded from school at age 15 after threatening violence against a staff member. He has also been arrested for drunk driving, each time showing no remorse or concern that other members of the public could have been hurt.
What personality disorder would most likely apply to this patient?
-narcissistic personality disorder
-histrionic personality disorder
-antisocial personality disorder
-borderline personality disorder
-dependent personality disorder
A 32 year old man with a background of bipolar disorder is reviewed in clinic.
He has recently been started on sodium valproate as maintenance therapy for his bipolar disorder after recovering from a recent episode of mood disturbance. He reports a number of recent symptoms that have been bothering him and wonders if they are due to the new medication.
Which of the following might be side effects of his sodium valproate?
-weight gain, hyperglycaemia and hypertriglyceridaemia
-Confusion, ataxia and bone marrow suppression
-Hair loss, weight gain and tremor
-Hirsutism, gingival hyperplasia and lymphadenopathy
-Tremor, hypothyroidism, nephrogenic diabetes insipidus
A 17 year old girl comes to the GP surgery complaining of absent periods for the past 6 months. She denies being sexually active and previously had a regular 28 day cycle since the age of 13.
On examination she is wearing multiple layers of clothing, and appears underweight and malnourished. You notice a fine layer of hair covering her skin.
Which of the following blood results when you expect to find, given the most likely diagnosis?
-hyperkalaemia
-high testosterone
-low levels of growth hormone
-hypercholestrolemia
-raised bHCG
A 32-year-old man presents with feelings of ‘something wrong with himself’. He has been having palpitations, sweating and hand shaking. He is worried about his daughter’s growth and wellbeing. He is also afraid of losing his new job, especially now that he is a single father. These thoughts make him feel unease almost on a daily basis. He has difficulties concentrating at work and getting to sleep. These feelings of ‘going crazy’ started six months ago when he had a divorce and when he secured a stressful new job. He enjoys spending time with his daughter over the weekend. He has no weight loss or reduced appetite. He denies substance or alcohol use. Physical examination shows tachycardia and coarse tremor.
What is the most likely diagnosis?
-adjustment disorder
-anxious personality disorder
-generalised anxiety disorder
-depression
-panic disorder
A 22-year-old man is detained in a psychiatric hospital for assessment and management of his first episode of psychosis. Unfortunately, one afternoon he becomes acutely agitated, and the medical team decide to administer a one-off dose of haloperidol to reduce the risk of harm. Later that evening, the nursing team note he is behaving unusually, sat up straight on his bed and staring into space. He feels hot and sweaty to touch, and his observations show a blood pressure of 190/110 and heart rate of 177 bpm.
What are the most likely findings from a set of blood tests taken from this patient?
A 55-year old man is rushed into the Emergency Department. He is complaining of severe abdominal pain, nausea, and drowsiness. He is known to have bipolar disorder and reports recently starting bendroflumethiazide.
He has a fine tremor and ataxic gait on examination.
His lithium level is 1.6mmol/l (normal level <1.5mmol/l).
A diagnosis of lithium toxicity is suspected.
What is the most appropriate management in this scenario?
A 35-year-old man presents to the Emergency Department with a 1-hour history of confusion. His family members found a few empty boxes of medications in his room, suggesting an intentional overdose. He has a history of depression, generalised anxiety disorder and opiate misuse.
His observations are as follows:
Temperature 37.0 °C
Heart rate 112 bpm
Respiratory rate 14 breaths/min
Blood pressure 92/54 mmHg
SpO2 94%
Chest and cardiovascular examinations show no abnormalities. His Glasgow Coma Scale (GCS) score is 14/15. He has bilateral pupil dilatation. Neurological examination shows no other abnormalities.
Initial investigations are as follows:
Capillary blood glucose – 4.5 mmol/l
Electrocardiogram (ECG) – prolonged QRS duration
Arterial blood gas (ABG) – metabolic acidosis
Which is the most likely drug to account for this presentation?
-paracetamol
-impiramine
-fluoxetine
-temazepam
-codeine
A 23-year-old woman presents to the Emergency Department with a paracetamol overdose. She discloses she took 50 paracetamol tablets after having an argument with her boyfriend. Her boyfriend wants to end this relationship, as she is constantly checking on him. She explains that she is doing this to prevent her boyfriend from having an affair. She initially just wanted to threaten her boyfriend, but she eventually took an overdose because she was distressed by her boyfriend’s ignorance. She has multiple previous attempted suicides, mostly due to relationship problems. She is living with her boyfriend, having left home when she was 18, as she says that her family is too controlling.
What is the most likely psychiatric diagnosis?
-paranoid personality disorder
-avoidant personality disorder
-emotionally unstable personality disorder
-dependent personality disorder
-histrionic personality disorder
A 49 year old woman presents to her GP with a 9 month history of nervousness. She feels generally tense and worried most of the time, experiencing palpitations, muscular tension, and fears of something bad happening to her on a daily basis. She is able to continue with her usual activities and this is the first time she has sought help. What is the most appropriate intervention?
An 80-year-old man is diagnosed with Alzheimer’s dementia in the memory clinic after extensive clinical evaluation, cognitive examination and MRI brain scan. His past medical history includes chronic diarrhoea, hypertension, heart failure and urinary urge incontinence. His ECG shows evidence of QT prolongation which appears to be longstanding. Which of the following is the most appropriate first line management of his Alzheimer’s?
-rivastigmine
-riluzole
-risperidone
-cognitive stimulation therapy
-donepezil
A 23 year old woman with a 12 month history of Anorexia Nervosa is admitted to the acute medical unit, due to rapid recent weight loss and concerns about her very low calorie intake (less than 500 kcals per day). In the absence of the ward dietitian, she is initiated on a mealplan of 2000kcal per day. After 3 days, she develops tachycardia and pedal oedema. What is the most appropriate treatment?
A 68-year-old woman presents with a 1-month history of low mood, anhedonia and anergia. She also has early-morning wakening, loss of appetite and weight loss. She says she cannot focus as much as before when reading newspapers or watching television programmes. She denies psychotic symptoms or suicidal ideations. She has a history of poorly controlled hypertension and atrial fibrillation and is taking metoprolol, warfarin, ramipril and amlodipine. She agrees to start a medication for her mood symptoms.
Which is the most appropriate pharmacotherapy?
-mirtazapine
-clomipramine
-fluoxetine
-venlafaxine
-meclobemide
A 27-year-old woman is brought to the emergency department 5 days after giving birth, by her partner who is concerned about her behaviour. He discovered her trying to lock the baby in a cupboard, which when questioned she reported an unfamiliar voice told her to do so. She also described unusual beliefs about the identity of the baby, thinking that it had been artificially implanted in her uterus by the devil.
Her bloods and observations are normal. She is not breastfeeding.
Which of the following is the most appropriate management of this patient?
-fluoxetine
-amoxicillin
-mirtazapine
-sertraline
-admission to mother and baby unit
A 78-year-old woman is on the ward after a hemicolectomy. She is not rousable, is flushed and has excoriations over her hands. She has decreased bowel sounds and a respiratory rate of 8 breaths per min.
What is the best treatment?
-change to fentanyl
-change to remifentanil
-naloxone boluses titrated
-naloxone full dose bolus
-change to alfentanil
A young female patient is having a history taken and suddenly stops talking halfway through explaining how she believes she hears voices at night. The silence is prolonged, and when she starts to speak again, she talks about how beautiful the weather is outside.
What type of thought disorder is exhibited?
A 26-year-old woman presents with a 2-month history of amenorrhoea. She previously had regular menstrual cycles. She is sexually active and uses barrier contraception but admits that she has reduced libido. She has gained over 3 kg in weight over the past 3 months. She was diagnosed with bipolar affective disorder 3 months ago and is taking risperidone. She denies having symptoms of mania or depression. Her urine pregnancy test is negative.
Which is the most appropriate investigation to confirm the diagnosis?
-lutenising hormone
-testosterone
-thyroid function test
-prolactin
-transvaginal ultrasound
True or false, dopamine receptor antagonists can cause hyperprolactinaemia?
True
A 47-year-old man is brought to the emergency department by police after he is found wandering the streets confused and disorientated. His gait is noted to be uncoordinated and he keeps knocking things over. Examination demonstrated nystagmus, he is noted to smell of alcohol.
Which of the following chemicals must be replaced to prevent the development of Korsakoff’s syndrome?
